Cystoscopic temporary ureteral catheterization during radical vaginal and abdominal trachelectomy.
ABSTRACT To describe the role of temporary retrograde ureteral catheterization at the time of fertility-sparing radical vaginal or abdominal trachelectomy in women with early-stage cervical cancer.
We analyzed a prospectively maintained database of all patients with cervical cancer who were explored for radical vaginal or abdominal trachelectomy at our institution. Cystourethroscopy and ureteral catheterization were performed prior to the vaginal or abdominal operation in all patients, except two pediatric ones. Temporary bilateral retrograde ureteral catheters were planned for all patients as part of our routine procedure to facilitate identification of the distal ureters. 5Fr whistle-tip or open-ended catheters were used and usually advanced to approximately 20 cm. Catheters were removed at the end of the operation in all cases. All catheters were inserted by a gynecologic oncology fellow or attending.
Between 11/01 and 12/05, 40 patients were taken to the operating room for planned fertility-sparing radical vaginal or abdominal trachelectomy. We previously reported on two pediatric patients; they are excluded from this report. The median age for adult patients was 32 years (mean, 31.6; range, 23-40). International Federation of Gynecology and Obstetrics (FIGO) stage included IB1 (26), IA2 (6), and IA1 with lymphovascular invasion (6). Thirty-four patients underwent radical vaginal trachelectomy and four underwent a radical abdominal trachelectomy. Two (5%) of 38 patients required immediate completion radical hysterectomy due to extensive endocervical disease (one in the vaginal group and one in the abdominal group). Bilateral ureteral catheters were inserted successfully in 37 (97%) of 38 patients and facilitated identification of the distal ureter during the dissection. In one case, the right ureteral orifice could not be successfully catheterized, and the case was completed with unilateral catheterization. The estimated time to perform this part of the operation was approximately 15-20 min. Twenty-eight patients (74%) had 5Fr whistle-tip ureteral catheters inserted, and 10 had open-ended catheters inserted. There were no intraoperative complications. Median hospital stay was 3 days (range, 3-7). Hematuria, evident in the drainage bag attached to the Foley catheter, usually resolved in 24-48 h. Two (20%) of 10 patients who had open-ended catheters inserted developed a transient rise in postoperative creatinine (1.7 and 3.5 mg/dl, respectively) compared to 0/28 patients who had whistle-tip catheters placed (P<0.001). Both were attributed to postoperative distal ureteral edema, and only one patient required reinsertion of temporary ureteral stents. No patient developed long-term urinary complications or fistulae.
Cystourethroscopy and bilateral retrograde ureteral catheterization by gynecologic oncologists is a simple and quick procedure that may facilitate identifying the distal ureter during radical vaginal or abdominal trachelectomy. We favor using 5Fr whistle-tip catheters as they may be associated with less ureteral mucosal trauma and subsequent postoperative edema. The skills needed for this procedure should be available to fellows in gynecologic oncology training.
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ABSTRACT: Abdominal radical trachelectomy is a fertility-preserving alternative to radical hysterectomy or chemoradiation for young women with stage IA2 to IB cervical cancers. Thirty-three patients were offered this procedure. The mean age was 30.5 years (range 23-37). Three procedures were abandoned because of positive pelvic nodes (two patients) and involvement of the margin between the amputated cervix and uterine fundus (one patient). Of the remaining 30 patients, 10 had stage IA2 tumours, 15 had stage IB1 and 5 had stage IB2. During follow up of a median of 47 months (mean 32 months, range 14-75 months), no recurrences have been detected. A normal menstrual pattern resumed within eight weeks of surgery in all but two patients. Five patients attempted to conceive. Three women have fallen pregnant, resulting in one first trimester miscarriage and two caesarean section deliveries at term. Our experience suggests that abdominal radical trachelectomy provides a method of treating women with stage IA2 to IB cervical cancers with conservation of fertility without apparently compromising recurrence or survival rates. It appears to provide equivalent oncological safety to a standard Wertheim hysterectomy using a technique familiar to all practising gynaecologic oncologists.BJOG An International Journal of Obstetrics & Gynaecology 04/2005; 112(3):366-9. · 3.76 Impact Factor
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ABSTRACT: Clear cell carcinoma of the cervix and vagina is rare in the pediatric population. Many of these tumors are associated with prior intrauterine diethylstilbestrol (DES) exposure. All DES-associated tumors are believed to contain microsatellite instability (MI). Historically, the recommended treatment is radical hysterectomy and pelvic lymphadenectomy, which result in infertility in all cases. Radical abdominal or vaginal trachelectomy and pelvic lymph node dissection is a new technique utilized in adult women with early cervical cancer who wish to retain fertility. This novel approach is also pertinent to the pediatric patient and is described in this report. A molecular analysis is also performed to determine if these are DES-associated tumors. Due to the narrow vaginal anatomy in pediatric patients, a vaginal approach is not possible, and an abdominal approach is performed. The resection includes the cervix, upper vagina, parametrium, and paracolpos. Pelvic lymphadenectomy is performed in a similar manner to the adult patient. Matched pairs of normal and tumor DNA from both cases were examined for evidence of MI using a consensus panel of microsatellite markers. Two girls aged 6 and 8 years and without history of DES exposure presented with vaginal bleeding. Vaginoscopy revealed cervical polyp in both cases. Biopsies demonstrated clear cell cancer stage IB1 in both patients. They underwent radical abdominal trachelectomy and bilateral pelvic lymph node dissection along with anastomosis of uterine isthmus to upper vagina. Intraoperative frozen-section analysis confirmed negative uterine and vaginal margins. No adjuvant treatment was given and both girls remain disease free. Neither tumor showed evidence for MI, confirming that these are not DES-associated tumors. To our knowledge, this is the first report of radical abdominal trachelectomy in the pediatric age group and it is likely to include the youngest patient with clear cell carcinoma of the uterine cervix not associated with DES exposure. This novel approach is feasible and appears safe in the pediatric age group.Gynecologic Oncology 05/2005; 97(1):296-300. · 3.93 Impact Factor
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ABSTRACT: To report the obstetrical results following vaginal radical trachelectomy (VRT), a fertility-preserving surgery in the treatment of early-stage cervical cancer. Retrospective review of our first 72 patients treated by a laparoscopic pelvic lymphadenectomy followed by a VRT from October 1991 to October 2003 with regards to their reproductive function. Patients' median age was 32 years old (21-42) and 53 (74%) were nulligravida. A total of 50 pregnancies occurred in 31 women. The majority (66%) had only one pregnancy, 19% had 2 pregnancies and 16% had 3 pregnancies or more. The rate of first trimester miscarriage was 16%, the rate of second trimester miscarriage was (4%) and 2 women (4%) elected to have pregnancy termination. A total of 36 pregnancies (72%) reached the third trimester. Of those, 3 (8%) ended prematurely at <32 weeks gestation, 5 (14%) delivered between 32 and 36 weeks and 28 (78%) delivered at term (>37 weeks). One newborn died of neonatal sepsis from E. coli infection and one died from cardiac malformation (trisomy-18). Seven patients (10%) had infertility problems: 3 from ovulatory causes of which 2 successfully conceived with IVF, one from endometriosis and low sperm count and 3 from probable cervical cause of which one conceived with IUI. One patient had a twin pregnancy following IVF and elected to have embryo reduction and subsequently delivered at 37 weeks. Based on our experience, the obstetrical results following VRT for early-stage cervical cancer are very encouraging. The majority of women can anticipate to conceive spontaneously and deliver near term.Gynecologic Oncology 07/2005; 98(1):3-10. · 3.93 Impact Factor